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BCBS denied my claim (Shingles Shot)
Old 11-30-2015, 12:45 PM   #1
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BCBS denied my claim (Shingles Shot)

AARGGGGHHHH!!!

I did not know if BCBSIL had any age restrictions on shingles vaccination, so I called their customer line. The person told me that it is 100% covered, no copay, nothing. I asked if I could go directly to a Costco Pharmacy, he verified they are in the network, and even gave me the address of my local Costco (I actually wanted him to give it to me, even though I know it of course, just to validate that he told me I could go to that specific one).

So I go to Costco a few days later (8/25), they said they would have it preped in 30 minutes, I came back and they ring me up for $217.05. They said it was denied, and I explain it should be covered. They say I could skip the shot, but I decide to pay, and deal with insurance later (big mistake!).

I call BCBSIL, they don't seem to have any record of it being requested, declined or anything, tell me to wait for the EOB to come through. Well, weeks go by, no EOB. So I call and explain, it took some time for them to decode the codes I had on the receipt, but this 2nd person told me it was submitted as a pharmacy claim, and I need to submit it as a Medical Claim (fill out a form, attach original receipts, mail it in), and she assures me it will be covered given the circumstances. I submit on 10/1. Two more weeks, and that gets denied.

More emails, and they say I needed my PCP approval before getting the shot. Well, they never told me that when I called, or when they asked me to submit more paperwork. I had ref #'s/names/dates for the calls. Another review (and they won't give me any no promise date for the review), and another DENIED.

Can I escalate this somehow? It just doesn't seem right that I call them, do exactly what they tell me, twice, and I'm still denied. It's not always easy decoding their documentation, I thought calling was the right thing to do. But I guess like the IRS, they don't necessarily give the right info, and they aren't responsible for giving wrong info? IS BCBSIL particularly bad in this regard, or are they all the same?

-ERD50
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Old 11-30-2015, 01:05 PM   #2
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I'm not sure what you can do about it this time but in the future I would recommend you record phone calls with insurance companies. Federal law only requires one party to give consent so as long as you are part of the conversation then you can record it.
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Old 11-30-2015, 01:12 PM   #3
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Normally it's usually only covered when someone is over 60 (sometimes 50). I've never heard of it ever being covered as a matter of routine if someone is under 50. Other than that it would probably require medical justification to be considered, such as something in your medical or family history that would indicate it.
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Old 11-30-2015, 01:19 PM   #4
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Normally it's usually only covered when someone is over 60 (sometimes 50). I've never heard of it ever being covered as a matter of routine if someone is under 50. Other than that it would probably require medical justification to be considered, such as something in your medical or family history that would indicate it.
That's why I called, though I was 60 YO at the time. Didn't know if it was an age 65 trigger or not.

aaronc879 - As far as recording the calls, maybe I should, but they are not denying anything that was told to me, they just don't seem to care!

Is there a state regulatory agency or something to complain to? I'm just extra miffed that they had me jump through another hoop of submitting all the receipts, just to deny it for something that had nothing to do with getting the receipts or not.

It's just so frustrating to call, do everything they say (twice), and still be denied. My larger concern is - what if this was much more than $217?

-ERD50
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Old 11-30-2015, 01:20 PM   #5
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ERD50, you have every reason to be very upset.

In an sincere attempt to make you feel at least a little tiny bit better, well, from what my brother told me about his shingles episode, it is definitely worth $217.05 even from your own pocket if you can avoid shingles.

Not that that will help much, because you're right, BCBS should not tell you one thing and do another. But still. You may have less money, but at least you don't have shingles, thank goodness.

Good luck on getting them to pay. They should and although I have little to no faith in insurance companies in situations like this, I sure hope they do pay. I'm just saying, that either way you are a winner here.
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Old 11-30-2015, 01:22 PM   #6
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Is there a state regulatory agency or something to complain to? I'm just extra miffed that they had me jump through another hoop of submitting all the receipts, just to deny it for something that had nothing to do with getting the receipts or not.
Yup. Right here https://mc.insurance.illinois.gov/messagecenter.nsf BCBS IL must have an appeals process as well, no guarantee you have been using it even though you have had lots of back and forth already.
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Old 11-30-2015, 01:24 PM   #7
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ERD50, you have every reason to be very upset.

In an sincere attempt to make you feel at least a little tiny bit better, well, from what my brother told me about his shingles episode, it is definitely worth $217.05 even from your own pocket if you can avoid shingles.

Not that that will help much, because you're right, BCBS should not tell you one thing and do another. But still. You may have less money, but at least you don't have shingles, thank goodness.

Good luck on getting them to pay. They should and I hope they do. I'm just saying, that either way you are a winner here.
Yes, I very likely would have agreed to pay out of pocket anyhow, so that takes some of the 'sting' out of it. I have known people to get the shingles, and $217 is cheap insurance against the possible issues they faced.

But of course, after being told it was covered, I expect it... to be covered! Silly me!

-ERD50
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Old 11-30-2015, 01:24 PM   #8
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That's why I called, though I was 60 YO at the time. Didn't know if it was an age 65 trigger or not.
I have never, post-ACA, ever heard of a shingles shot NOT being considered a 100% covered "preventative" vaccination if someone is 60+ with an ACA-compliant policy. Do you receive out of network pharmacy benefits? The only other thing I can think of, if you were at least 60, is that your plan didn't cover out of network pharmacy benefits and the out of network pharmacy provided the shot (and the person you talked to on the phone made a mistake). Otherwise, this seems like it should be a slam dunk in terms of being covered.
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Old 11-30-2015, 01:29 PM   #9
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Yup. Right here https://mc.insurance.illinois.gov/messagecenter.nsf BCBS IL must have an appeals process as well, no guarantee you have been using it even though you have had lots of back and forth already.
Thanks! I think I'll 'threaten' them with this, and see if that loosens up their appeal process.

I've just been using their secure email back-and-forth, I didn't see any other more formal appeal process on the site, but I'll take another look.

Of course, the amount of time I end up putting into this is getting down to minimum wage... probably what they are counting on? But again, what if this happened on a larger bill? What do I need to do to make sure I'm complying with a process, when they don't even know the process? I guess that's my bigger concern.

-ERD50
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Old 11-30-2015, 01:29 PM   #10
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It's probably good to have the written document in hand that spells out exactly what is covered as part of your insurance policy.

I needed to go down this road, after the fact, when DW's "well-woman" screening tests were denied.

As it turns out her employer, who defines the coverage, never provided ICD-10 codes to the insurance company. They provided the legacy codes for the procedures by likely copying-and-pasting from the prior years document.

Insurance company, not digging into it, would just deny the procedures and say thay weren't covered.

Through much Internet research was able to cross-reference the old codes to the new codes and finally got someone on the line who appreciated the issue whan I said that the billed codes were the newer versions of the legacy codes which she could see on her list.

Not fun. I wonder how many ladies just accepted the insurance company line that the procedures were not covered.

Oh - by the way - Medical Lab was billing me the full retail rates on the tests - not the heavily discounted insurance negotiated rate. They wouldn't budge on this (until Insurance Co. paid them the negotiated rate and all was then resolved).

So in summary, you can use the formal appeals process, as I was considering it, but you probably only get one shot at it.

On the other hand, you can call the customer service number multiple times as you obtain more information that is inconsistent with what they told you the previous time.

Either way, good to have access to the written policy documents that define your coverage.

If there is an age restriction on the shingles vaccination than it will be called out in writing somewhere.

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Old 11-30-2015, 01:30 PM   #11
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I got mine at age 59 years 11 months. Got into a fist fight with the pharmacist who said I was too young, even though I was paying cash ($250) . He finally relented . BCBS would only pay, then, if over 65.

Nothing easy about this shot.
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Old 11-30-2015, 01:33 PM   #12
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Originally Posted by ziggy29 View Post
I have never, post-ACA, ever heard of a shingles shot NOT being considered a 100% covered "preventative" vaccination if someone is 60+ with an ACA-compliant policy. Do you receive out of network pharmacy benefits? The only other thing I can think of, if you were at least 60, is that your plan didn't cover out of network pharmacy benefits and the out of network pharmacy provided the shot (and the person you talked to on the phone made a mistake). Otherwise, this seems like it should be a slam dunk in terms of being covered.
No, the pharmacy is in network, they are saying I needed approval from my Primary Care Physician before getting the shot. And my stance is that when I called, they just told me I could go to the pharmacy directly, so I did.

Had I known I needed PCP approval, I would have gotten it, no big deal, and that would have saved me $217.

Well, even if I don't get anywhere, maybe this will help save someone else some grief. But since the rules may be different for many, not sure how much it will help, but at least some will be warned.

-ERD50
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Old 11-30-2015, 01:37 PM   #13
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Thanks! I think I'll 'threaten' them with this, and see if that loosens up their appeal process.

I've just been using their secure email back-and-forth, I didn't see any other more formal appeal process on the site, but I'll take another look.

Of course, the amount of time I end up putting into this is getting down to minimum wage... probably what they are counting on? But again, what if this happened on a larger bill? What do I need to do to make sure I'm complying with a process, when they don't even know the process? I guess that's my bigger concern.

-ERD50
My guess is your dispute is being treated like a complaint. Appeals are different, more formal, and subject to some regulation. See here https://www.healthcare.gov/appeal-in...ision/appeals/
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If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.
You can ask that your insurance company reconsider its decision. Insurers have to tell you why they’ve denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions.
Letting BCBS know you may take it to the state insurance regulator probably won't help, but making sure you have used, or attempted to use, the formal appeals process should help with the insurance regulator.
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Old 11-30-2015, 01:44 PM   #14
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No, the pharmacy is in network, they are saying I needed approval from my Primary Care Physician before getting the shot. And my stance is that when I called, they just told me I could go to the pharmacy directly, so I did.

Had I known I needed PCP approval, I would have gotten it, no big deal, and that would have saved me $217.
Oh, OK, I get it now. Is this an HMO? Sounds like it, if the PCP has to be the "gatekeeper".

I guess on the brighter side, $217 (with the added benefit of avoiding shingles) is a relatively cheap education about how your insurance works. Doesn't mean it doesn't sting and the principle still sucks, but in the grand scheme of things, if it makes you smarter as a health care consumer, could have been a lot worse.
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Old 11-30-2015, 01:48 PM   #15
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I'm not sure what you can do about it this time but in the future I would recommend you record phone calls with insurance companies. Federal law only requires one party to give consent so as long as you are part of the conversation then you can record it.
Just for the record, not all states allow such a wide latitude. In some states both parties must consent in advance. This tripped me up once when I planned to record an in-person conversation. My attorney strongly advised against it based on the law of that state. Maybe phone calls are under a different law, but I doubt it.
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Old 11-30-2015, 01:53 PM   #16
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Oh, OK, I get it now. Is this an HMO? Sounds like it, if the PCP has to be the "gatekeeper".

I guess on the brighter side, $217 (with the added benefit of avoiding shingles) is a relatively cheap education about how your insurance works. Doesn't mean it doesn't sting and the principle still sucks, but in the grand scheme of things, if it makes you smarter as a health care consumer, could have been a lot worse.
Yes, HMO. Agreed, I should probably just get over it and look at it as 'tuition'. But I guess that is what is bugging me - OK, I learned about this particular case, but what about the next thing? If I can't rely on them helping me to understand what to do, what do I do?


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My guess is your dispute is being treated like a complaint. Appeals are different, more formal, and subject to some regulation. See here https://www.healthcare.gov/appeal-in...ision/appeals/

Letting BCBS know you may take it to the state insurance regulator probably won't help, but making sure you have used, or attempted to use, the formal appeals process should help with the insurance regulator.
Interesting - I googled " how appeal claim "blue cross blue shield" Illinois ", and found a link to their appeals process. What is odd is, I could NOT find it when I was signed in. They have it hidden away on another site not linked to the member site. The first ones I found were for providers, so that made sense, but this one does look like the customer end:

https://connect.bcbsil.com/my-covera...enied-now-what

-ERD50
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Old 11-30-2015, 03:14 PM   #17
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When I went for my shingles shot at CVS, I was told that BCBS denied it. I asked how much the shot was, figuring that if it was $20 I'd just pay it. They said: $250. I said "I'll be back".

Called BCBS and found that they didn't know I was over 60 (ha!) but that it was now approved.

I went back, it was approved and I got my shot. The pharmacist said that I was the first person EVER to not pay the $250 for the shot!
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Old 11-30-2015, 04:41 PM   #18
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Wow - well, I guess when you are in an HMO you need a prescription/order/referral from your PCP for everything.

I had no trouble going straight to Costco, because I was in a PPO at the time.
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Old 11-30-2015, 05:04 PM   #19
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Interesting - I googled " how appeal claim "blue cross blue shield" Illinois ", and found a link to their appeals process. What is odd is, I could NOT find it when I was signed in. They have it hidden away on another site not linked to the member site.
Now that reminds a lot of what it was like to deal with BCBSIL when I was was on the group policy from w*rk. After the regional insurer we used for 2015 hiked next year's rates substantially I had selected a 2016 plan with BCBS, but I guess it's not too late to change my mind. I really don't need that kind of frustration.
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Old 11-30-2015, 05:27 PM   #20
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Just for the record, not all states allow such a wide latitude. In some states both parties must consent in advance. This tripped me up once when I planned to record an in-person conversation. My attorney strongly advised against it based on the law of that state. Maybe phone calls are under a different law, but I doubt it.
You are correct. State laws can be stricter than Federal laws and its illegal in some states to record a conversation without both parties' consent. If youre going to record a phone call, you need to make sure you know what state the other person is in and abide by the laws of both states.
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